Has Student Ever Taken Private Lessons? (If Yes, for what and how long) *

PARENT CONTACT INFORMATION

Full Name of Parent / Guardian 1 *

Full Name of Parent / Guardian 1

First Name

Last Name

Full Name of Parent / Guardian 2 *

Full Name of Parent / Guardian 2

First Name

Last Name

Home Mailing Address *

Home Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent E-Mail Address *

Primary Phone *

Primary Phone

(###)

###

####

Secondary Phone *

Secondary Phone

(###)

###

####

Work Phone *

Work Phone

(###)

###

####

Emergency Contact Name *

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone *

Emergency Contact Phone

(###)

###

####

Relationship to Student *

MEDICAL

Family Physician *

Name of Family Physician

Family Physician Phone Number *

Family Physician Phone Number

(###)

###

####

Medication *

My child takes medication on a routine basis.

Yes

No

Medication Details

If you answered "Yes" above, please list any medications being taken by your child on a regular basis including non-prescription drugs.
Important: Make sure that your child arrives at MAMM each day with the exact amount of medication needed for that day. Keep all medications in their original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and frequency of
administration. All medications must be given to the camp director when the child arrives each morning.

Allergies *

Does Student have any Allergies?

Yes

No

Allergy Details

If you answered "Yes" above, please provide us with all of the necessary information regarding your child's allergies.

Family Dentist *

Name of Family Dentist

Family Dentist Phone Number *

Family Dentist Phone Number

(###)

###

####

Other Information

MAMM is a unique learning situation where individual expression and teamwork go hand in hand. In order to help your child get the most out of their time at MAMM, we ask that you provide us with personal information regarding any LEARNING, BEHAVIORAL, or PERSONAL DIFFICULTIES they may have.
Important: Any information you provide will be kept in confidence and will only be used to help provide a healthy learning environment for your child. If we are not aware of your child’s needs, we cannot help. With your help, we can make this program one of the most enjoyable educational experiences that your child will ever have.

Music/Photo/Video Release *

I hereby release the use of music, photographic and video images and work product of the above participant for the purpose of promotion and display to the general public.

Yes, I Agree

No, I Decline

MAMM Policies *

This health form is correct to the best of my knowledge, and the person named above has permission to participate in all activities except as noted. If I cannot be reached in an emergency, I hereby give permission to the physician selected by the director to hospitalize, secure proper treatment for, order injection for, or anesthesia for surgery for the person named above. In addition, I have read and understand MAMM’s policy above, regarding prescriptions, and agree to MAMM policies.

Yes, I agree.

Refund Policy *

In order to cancel, please email office@maineacademyofmodernmusic.org and include the reason for the cancellation. FULL tuition will be reimbursed if notice of cancellation is received 30 days in advance of the start date of camp. PARTIAL (50%) tuition will be reimbursed if notice of cancellation is received 29-14 days in advance of the start date of camp. Tuition fees are forfeited and NO refund will be issued for cancellations received two weeks or less prior to the start date of camp.
Cancellations due to serious illness or injury may receive a full refund although a medical note from a doctor must accompany the written cancellation request. If your child needs to reschedule and attend a different camp then tuition may be transferred and applied to other camps. Please note that spaces are limited so other MAMM camps may be full.